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HomeMy Public PortalAbout5043ALESSANDRO AVE_Building (8) WORKERS'.COMPENSATION DECLARATION nt to* self insure, o as certif carte of Worke srlCompensat oificate of n eInsurance, A P P L I AT I O N FOR BUILDING PERMIT or a certified copy thereof (Sec. 3800,.Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No. Company BUILDING )' ❑ Certified copy is hereby furnished. //FOR APPLICANT TO FILL IN p ADDRESS '�d?3 //�I�r�'f�rCf �'�� ❑ Certified copy is filed with the county building inspec- ADDRESS � 0 ks h ji O>� i tion department. e I %�� Date Applicant CITY e Lj< ZIP�i"r LOCALITY f ,,NO.,OE_,BLDGS:, j a NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' SIZE OF LOT ((, NOW ON LOT / Asa- CROSS ST. Gilf n COMPENSATION INSURANCE ; g >>>.�r!!yy Z ASSESSOR ,e� (This section need not be completed if the permit is for one TRACT BLOCK V�� LOT NO.OQ MAP BOOK, �l� V PAGE O PARCEL(902 hundred dollars ($100) or less:) „ OWNER' (i11/G NO2u&E! /01 USE ZONE MAP NO. / /a16S I certify that in the performance of the work for which This ��^�:,r.,,:� 1,..,n .,,, SPECIAL } permit is issued, I shall not employ any person in any manner �,'i ADDRESS" " »µie / V �� CONDITIONS O so as to become subject to the Workers' Compensation Laws. � f d . CITY. /ei 'l . ZIPtG�J' �' �© U Date Applicant ARCHITECT OR:. TFL.n NOTICE TO APPLICANT: If, after makingthis Certificate of ENGINEER ` '' NO: �` DISTRICT GROUP. TYPE FIRE PROCESSED BY CONST. ZON Exemption, you should become subject 'to the Workers Q / U Compensation provisions of the Labor Code, you must forth 'ADDRESS` N with comply with such provisions or this permit shall ,be , TEL. STATISTICAL CLASSIFICATION APT. CONDO. Z deemed revoked. ;`•`- CO(4TRACTOR NO.r LICENSED CONTRACTORS DECLARATION`' LIC. CLASS NO. DWELL. UNITS I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS- , ,`, " NO.", f. .>;f SEWER MAP (commencing with Section 7000)of Division 3 of We Business LIC. and Professions Code,and my license is in full force and effect. CIN", '` CLASS BK PG VALIDATION SQ.,F.T. �. NO. OF NO. OF / CHECK License Number Lic. Class SIZE„; O STORIIESFAMILIES �p p ONE Contractor Date DESCRIPTION OF WO'RtK#4AD 06A fl�P-� NEW ❑ $AL�UATION 000. El am exempt under Sec. TITMA)S Ste(es es DD a J lyN0 ALTER ❑ , B.&P.C. for this reason � 1 /V�� r _40, — REPAIR ❑ $ Date: USE OF O a DEMOL ❑ EXISTING BLDG. esi Signature APPLICANTl s TEL. J FINAL £.- OWNER-BUILDER DECLARATION (PRINT) yr1 NO. �J2�/ `• �F I hereby affirm that I am exempt from the Contractor's License �''p� DATE �/ ^y i-t x! y a y Law for the following reason (Section 7031.5, Business and ADDRESS)v iolezadkewe. 7&pole i// FINAL " Professions Code): PRESENT By a = -! BUILDING ❑ I, as owner of the property, or my employees with ADDRESS ` t_{1 AL 105 25 wages as their sole compensation,will do the work and the structure is not intended or offered for sale(Section LOCALITY n ,:K 7044, Business and Professions Code.) MOVING TEL. _ I, as owner of the property, am exclusively contracting CONTRACTOR NO. with licensed contractors to construct the project.(Sec- ADDRESS tion 7044, Business and Professions Code.), REQUIRED TOTAL SETBACK FROM EXIST. CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH 7" `•=1i " - 'S' I hereby affirm that there is a construction lending agency for FRONT y s;a w;- the performance of the work for which this permit is issued P.L. L 'r II' '=° '= (Sec. 3097, Civ. C.). SIDE- P.L. IDE-P.L Lender's Name LDMA Ref. # m P.C. Fee$ Permit Fee Lender's Address 7 a I certify that I have read this application and state that the Issuance Fee /= LDMA P/C# 8 above information is correct. I agree to comply with all-County Investigation Fee �^ " ordinanc s and State laws relating o b ilding construction, Total F61_ &S_. LDMA Perm. # and her out rize re e t i s o his C nt to enter u t bou or y f ins e purposes. p 0 7"Z�'f/ SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of AI ly arit or Agent Date